Are you safe in your relationship?
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This questionnaire is designed for female. It helps to identify the safety of your relationship.
Please complete these questions in a private and comfortable environment. If you feel any distress while answering the questions, please take a break, or stop and try again at a later time.
Please complete these questions in a private and comfortable environment. If you feel any distress while answering the questions, please take a break, or stop and try again at a later time.
Question 1(a)
Within the last year, have you been emotionally hurt by someone?
Examples of emotional hurt:
The partner:
Examples of emotional hurt:
The partner:
- Yells at you
- Is hypercritical towards you
- Shames you in front of friends/family/strangers
- Ridicules you (e.g. about her appearance or behaviour)
- Monitors you
- Isolates you from friends/family
- Threatens to hit you
- Threatens to throw something at you
- Accuses you (e.g. of doing something wrong)
- Destroys something belonging to you
If yes, by whom (check all that apply)
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Question 1(b)
Within the last year, have you been physically hurt by someone?
Examples of physical hurt:
The partner:
Examples of physical hurt:
The partner:
- Throws something at you
- Pushes or shoves you
- Slaps you
- Grabs you
- Drags your hair
- Threatens you with a weapon
- Hits you
- Beats you up
- Kicks you
- Chokes you
- Burns or scalds you
If yes, by whom (check all that apply)
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Question 1(c)
Within the last year, have any one forced you to have sexual activities?
Examples of forced sexual activities:
The partner:
Examples of forced sexual activities:
The partner:
- Insists on having sex with you against your wish (he may or may not use force)
- Ignores your request to use condom when they have sex
- Insists on having oral or anal sex (he may or may not use force)
If yes, by whom (check all that apply)
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Question 2(a)
If you have been pregnant, have you been emotionally hurt by someone?
If yes, by whom (check all that apply)
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Question 2(b)
If you have been pregnant, have you been physically hurt by someone?
If yes, by whom (check all that apply)
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Question 2(c)
If you have been pregnant, have any one forced you to have sexual activities?
If yes, by whom (check all that apply)
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Question 3
Are you afraid of your partner or anyone you listed above?
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